At the time of the writing of this article, a substantial part of the world population is in partial or total lockdown due to the pandemic caused by the SARS CoV-2 virus. This health emergency, which has hit our country of Spain hard, has transformed and will continue to transform our social customs, our economy, and, obviously, our health care system in ways that are difficult to predict. This article aims to anticipate some of the changes that are coming in the field of mental health and care for people with mental disorders, as well as the specialty that deals with it: psychiatry. Psychiatry, in its broad sense, also includes aspects of medical psychology and prevention and health promotion that are undoubtedly part of the specialty's doctrine.
Psychiatry as a medical specialty
Many psychiatrists have returned to serve as general practitioners and are reinforcing patient care teams dealing with COVID-19. At this time, there is recognition of the value of basic medical training and the initial stages of residency, during which the practical training in medicine and neurology essential for the good practice of psychiatry takes place. The current health emergency has once again reminded us that psychiatry is a medical specialty and that psychiatrists can and should act as doctors, both in the field of our specialty and when, as in the current crisis or due to other circumstances (accidents, disasters), our most fundamental medical knowledge is required. Without diminishing the complexity of the psychological and social determining factors that are so important to the practice of psychiatry, the present crisis does and will to continue to emphasize the medical model that underlies the practice of the specialty and the value of good public health.
The psychological aspects of medical practice
Just as psychiatry is a medical specialty, medicine cannot be dissociated from the psychological aspects of medical practice that are so important for the practice of any specialty that cares for the sick, including, obviously, psychiatry. In the midst of a health crisis, hospitals have been compelled to develop protocols for the psychological care of patients, their families, and professionals themselves. Patients need this because the infectious characteristics of COVID-19 require they spend long days and weeks in social isolation, separated from their loved ones and comforted only by professionals completely shrouded in masks and gowns that make them practically unrecognizable and who do much of their observing from a distance. For the same reason, families are more in need of information and support, since they cannot be with their hospitalized loved ones. Health professionals, for their part, are working longer hours than ever, under often precarious conditions due to lack of equipment and resources, caring for patients with health problems that are different from those they usually see and that comprise a less than predictable risk of sudden deterioration and death, while they watch their own strength undermined by the wear and tear of so much professional dedication,1 as we will discuss in greater depth below.
This epidemic will showcase psychological support as a health instrument for the three aforesaid groups, and it will reinforce the collaboration between psychiatrists and clinical psychologists, together with nursing and social work teams, in the practice of health psychology.
Mental health home care
Home care, including its more intensive version, hospitalization at home, is playing a key role in avoiding hospital admissions for mental disorders (which would put patients at greater risk of contracting COVID-19) and ensuring good care of patients who, for a variety of reasons, are not candidates for telemedicine care. The home care staff must be tested for COVID-19 and must be adequately protected, keeping a safe distance at all times. Although not all patients are candidates for this type of care, the COVID-19 pandemic has shown that home care can, in many cases, substitute for admission to a psychiatric hospitalization unit, especially in situations such as the current one where many psychiatric wards have had to be converted into COVID-19 wards, and it allows certain treatments such as long-term injectables to be given, white blood cell counts to be monitored in patients treated with clozapine, and lithium levels to be checked.
This home care is also important for people with intellectual disabilities and/or autism and patients with severe mental disorders and poor functionality who live with older caregivers.
During the pandemic, it is advisable to call the homes of all such patients and, if there is no answer, to provide a home visit, since the caregiver may have died and the person with a mental disorder may be in need of care. In the case of homeless people, many of whom have mental disorders, home care is a misnomer but takes on a similar meaning when caring for this group in shelters and spaces used for their lockdown. In countries without a powerful public health system, an upswing is expected in this group so vulnerable to diseases and economic crises.
Finally, nursing homes, severely penalized by the infectious disease, have also been candidates for home treatment, avoiding unnecessary transfers to hospitals. In short, home care, including hospitalization at home, is also a resource to be promoted after the acute phase of the pandemic.
Telepsychiatry: online community mental health care
One of the first measures universally adopted in all countries is a transition to remote care through outpatient televisits via telephone, chat, or video call. Undoubtedly, the field of mental health is one that is best suited to this change since physical examination is generally less crucial than in other conditions. Even so, the psychopathological examination is more limited, especially if the audio-only telephone route is used without visual information. Although it is foreseeable that after the pandemic there will be a return to the format of face-to-face visits, this crisis has made it clear that many unnecessary trips can be saved and that remote communication can, at least in part, replace or complement the in-person visit. This is undoubtedly one of the lessons we would do well to learn after the COVID-19 outbreak.
Big data approaches will undoubtedly be incorporated as a tool to fight the virus, as has been done in other countries such as China and South Korea. All those that have a digitally literate population and access to smartphones will use these resources to navigate the return to social normality. Therefore, mHealth or mobile health is going to play an increasingly important role and can also be used to benefit mental health provided that the aspects of confidentiality and data protection are properly taken into account. In Spain, the Spanish Society of Psychiatry has made a series of recommendations in this regard. Post-COVID-16 Psychiatry will use digital resources, such as apps, much more to provide mental health services, as an instrument of both case management and empowerment.